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Removing Multiaxial diagnosis

One key change is DSM-5 that will affect clinicians’ practice is the “removal” of the multiaxial system of recording diagnoses. Whether this is a good thing or a bad thing is unclear. It could be argued that 100% of clinicians misunderstand the multiaxial system and 100% use it poorly. There is also an argument to be made that some percentage of those using it (ahem, insurance companies) cause damage to patients and the mental health system at large.

Anyway, it’s still unclear how the new diagnosis format will work. The statement from the APA press release was general:

DSM-5 will move to a nonaxial documentation of diagnosis, combining the former Axes I, II, and III, with separate notations for psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V).

It’s not certain in what way notations are different from having axes, but there it is. Something useful would be a version of the International Guidelines for Diagnostic Assessment (IGDA 2003), see the image below, with a line listing mental and medical disorders, a scale for identifying particular disabilities experienced by the patient in different spheres, a line for the psychosocial/contextual factors, and a line for the patient’s assessment of their quality of life. Perhaps as a matter of clinical practice, if the APA doesn’t suggest it, clinics and clinicians could start to measure ongoing patient satisfaction with their lives. The PHQ-9 is cumbersome to use on a regular basis, but the IGDA has a simple 10-point rating.

With any luck the General Assessment of Functioning is dead as well; of all parts of the current system, it is probably the least understood and most misused. It doesn’t measure disability well or help focus on areas in the patient’s life that require attention. Again, the IGDA Axis II may be a better approach.

The original request to ditch the 5 axis system apparently came in 2004, showing how long it takes to make changes in the APA: effectively 9 years and hundreds of thousands of bad practices. By the way, did you know that we could specify maladaptive defense mechanisms on Axis II? I wonder what the insurance companies would have made of that.

Dr. Allen Frances has been a gadfly in the move to the DSM-5. At times his criticisms are cogent but this 2010 critique is weak:

Deleting the Multiaxial System. This would result in the loss of much valuable clinical information. Multi-axial diagnosis provides a disciplined approach to distinguishing between state and trait (Axis I versus Axis II) and to determining the contributions of medical conditions (Axis I II) and of stressors (Axis IV) to the diagnosis and treatment of psychiatric disorders. The GAF score (Axis V) provides the most convenient and familiar rating of overall functioning. No compelling rationale is offered for making so radical a change.

Does the GAF really provide the rating of function that Dr. Frances asserts? But notice something else he says: the system was intended to separate state conditions from trait conditions. In practice, that has turned out to be a poor choice. It created a ghetto so that personality disorders and intellectual disability were handled differently from more “treatable” disorders. In other words, they were demoted, ignored or untouchable. Of course in New York, we have a whole state agency, OPWDD (formerly OMRDD), devoted in part to the intellectual disabilities (formerly mental retardation), but we don’t have an office dealing with personality disorders. Yet, these latter cause much distress and disability and increasingly are considered treatable. Putting them on Axis II gave carte blanche to insurers to refuse to pay for treatment and to clinics to pretend not to treat them. Yet every day we work treating people suffering from personality disorders or perhaps more generally, personality traits that are disabling. How does this make any sense at all?

Hello Jen, sorry for the delay in responding to your comment. Just getting the hang of wordpress.

I’m not sure what you mean by “official”. This is the form prepared by the World Psychiatric Association. There might be more clarity if you look at their documentation here: http://bjp.rcpsych.org/content/182/45/s52.full.pdf. In it, they state that they qualify “massive” as impairments exceedingly high in both severity and frequency. As they don’t give examples, it is hard to see what they would view as high. As in many areas of diagnosis, there seems to be much left to the diagnostician. As to the issue of labels, I personally avoid “labeling” and am certainly more comfortable by ranking someone’s functional impairment as a “5”, leaving the linguistic term to be implied. The way of the world is that if a numerical ranking of 5 is given, that will be considered by some as a pejorative.